Saturday, May 19, 2012

"Effect of exercise on perceived stress"?

I have been exercising regularly (several times a week, at least a half hour of cardio and about 45 minutes of horizontal exercise, abs etc.) for about 6 months now. 
Yeah, I lost some weight. Yeah, my size shrank. A lot actually. No, I'll never be athletic. I'll never "look" thin or fit or muscular. But I do have to say, I feel way better. Waaaaaaaaaaay better. Shocking, I know... 

Not physically. I do not feel better physically. I never felt bad in the first place, physically. I always felt fine physically, even when I weighed 50 pounds more than I do now. 

I don't feel stronger, or more coordinated, or more powerful, or that I have more endurance for life. Yes, I can last longer on a treadmill or whatever (as long as there is a TV set in front of it), but not for regular life.  

I can't really do more stuff.. What I can do, now, though, is stew less about the stuff that there is to do. I have different feelings about the mess that is life. 

My attitude is better. I am more dispassionate about dealing with what needs to be done. I feel less helpless in the face of it all. I feel less despondent about how, realistically, none of it probably matters now, or will in the future. Not even a pick. After I die I will be gone, that's all there is to it. No lasting dint on the world. And that's all fine by me, on every level of myself. On as many levels as I can currently perceive, at least. 

All that matters is what's right in front of my nose, to be done either Right Now, or Soon. Until my long range plans show up inside that front-of-the-nose zone, I don't care. Not anymore. 

I've lowered the pressure I put on myself somehow. For now at least. I don't gaze around at the rest of my life, a landscape littered with "Stuff that Must be Taken Care of Before the Final Croak" and worry over what course to plot to get as much done as I can. I seem to have just started to move out in any old random direction, and do whatever there is right in front of me, there. Which opens a path to the next Thing That Must be Done. Then the next after that. I'm letting the path emerge of its own accord instead of feeling I must be solely responsible for planning, controlling, and executing it. I don't care. Whatever happens will happen. It will all be fine. Nothing really matters anyway. 
(It would be nice if this turned itself into "don't worry, be happy", but I'm fine if that never happens. Just getting from where I was to here feels like progress. I know I can't have it All, and I've always been OK with that.) 

Some internal friction that used to annoy the bejeebers out of me, though, seems to have simply...  disappeared. Moving more, is now/has become, a mental and emotional habit, not just a physical habit. Exercise helped me move off the 'mood' square I used to be stuck on. 

I googled "effect of exercise on perceived stress" and for 2012 alone there are 28,900 papers in google scholar. One would have to weed carefully, of course, and toss out all papers that did not specifically link exercise specifically to reduction of specific "perceived" stress - this is what a true-blue scholar would have to do, which I do not pretend to be, as I'm not trying to earn a PhD or anything..  still, there is a whole ball park to be explored, just for fun maybe. Maybe in some other lifetime. 

TEDxBayArea - KellyMcGonigal - The Science of Willpower

Monday, May 14, 2012

"Know Your Neurons: The Discovery and Naming of the Neuron" (SciAm)

LINK----> Know Your Neurons: The Discovery and Naming of the Neuron

This caught my eye today, by Ferris Jabr ( @ferrisjabr ). 

The third paragraph:
"Only recently, however, have I begun to recognize and appreciate the extraordinary diversity of cells in the nervous system—cells that differ from one another more than the cells of any other organ. Some neurons send electrical signals along fibers that stretch several feet; other neurons’ branches extend only a few millimeters away from the cell body. Some neurons possess a fractal beauty similar to that of ferns and corals: Purkinje cells, for example, often sport finely branched nets, like a sea fan. But some of their neighbors look more like tangled tumbleweeds. One neuron might appear more or less round under the microscope—like a firework frozen in climax—whereas another might spider through the brain like a daddy longlegs. Neurons not only differ in shape—different types of neurons turn on different sets of genes and not all neurons use the same chemicals to communicate. Excitatory neurons mostly stimulate other cells; inhibitory neurons prefer to stifle. Most neurons fire in patterns, but their tempos vary: some keep a steady beat, others remain largely silent except for the occasional burst of activity and still other cells continually fire like a trigger-happy toddler playing laser tag. To summarize: not all neurons are exactly alike. The brain contains multitudes."

I think that paragraph is just beautiful.  

Sunday, May 13, 2012

Book review: "The Graded Motor Imagery Handbook"

With the release of The Graded Motor Imagery Handbook this spring, Noigroup (Neuro Orthopaedic Institute) takes itself, and by extension, the physiotherapy profession, out of “tissues”, past the foramen magnum, and into the brain, which provides (at least to this PT reviewer) a bridge across the Cartesian chasm that long ago divided the branch of the profession which considers itself “Neuro”, from the one that considers itself “Ortho”; this bridge is built from fifteen years of deep Noigroup marination in neuro and pain science and education.

It’s a team effort, coauthored by G. Lorimer Moseley, David S. Butler, Timothy B. Beames, and Thomas J Giles; it manages to deliver complex material with whimsy and friendliness. The book’s size, shape, font, flat spiral binding, colourful chapter and page layout, and artwork, engage the reader, and make the content seem much less daunting to study and learn. In a mere 143 pages, The GMI Handbook ambitiously (and successfully) tackles multiply-leveled objectives:

1. Introduce and explain the entire topic to clinicians and patients;
2. Explain why the topic deserves attention, understanding, and implementation by clinicians and patients;
3. Provide a conceptual trail;
4. Provide products, services and support to clinicians and patients to implement the program.

We are given an introductory tour of the book by Butler, who, as an adult educator as well as a longtime PT, speaking to both practitioners and patients, admits this is new territory for PT; although the navigating map may still lack fine detail, he is confident that clinical reasoning should suffice to keep us on track, and his enthusiasm for exploring and charting this new frontier is contagious.

Patients who have persistent, non-medical pain, he explains, need to “exercise their synapses,” lubricate them with knowledge, first; then, subsequently, moving their physicality may feel easier. All behaviours occur within a given context, defined as “the temporary environment of an action or planned action”:

“Knowledge is a very special context. It can be de-threatening, give meaning to your symptoms, provide explanations, help with compliance, allow problem-solving, link to future goals, allow progression of treatment and it can be passed on to other people like a useful virus.” - [p. 7]
Knowledge can be superficial or deep; a new idea will challenge many old ideas, may jostle them aside somewhat. A learner (such as a person with persistent pain) who is prepared for this, will be able to entertain options for moving old beliefs aside, permit new information to enter safely and deeply into his or her own brain, so that it can help change the overall synaptic structure of the brain itself - the ultimate goal is to provide one’s brain with new options based on new information, so that it may eventually change its pain production and pain perception.

The second chapter by Moseley lays out the map of this new territory in as much detail as the book allows for. He recounts his personal journey toward this frontier, reading Ramachandran, meeting Butler, becoming interested in mirror therapy. He explains ‘neurotags’, defines them as, “a network of interconnected neurons..distributed throughout the brain. When a neurotag is activated it produces an output. The output defines the neurotag” [- p 24].

The neurotag is not the bread you smell: it does not produce the odour itself, does not detect it. The neurotag is not the neck pain you feel: it does not produce the neck pain, nor does it detect it. The neurotag is the experience of smelling the bread, the experience of feeling the neck pain. In other words, it is not primary sensation - it’s a kind of “learning” that has occurred by natural synaptic connection. A neurotag will activate when a threshold is reached, and when its member brain cells fire in concert, with no non-member cells firing at the same time. A ‘sensitized’ neurotag for experiencing pain is conceptualized as one whose activation threshold is too low, and whose nearby non-member neurons are too inactive, and therefore don’t or can’t contribute to inhibition.
For most people with pain, actual movement hurts. Without practice, parts of the brain that produce movement have become underused, and their synaptic strength has started to degrade. Primate brains are visually dominant. Humans are primates. Therefore, visual systems are recruited to assist - hence the term, graded motor imagery.

“Explicit” graded motor imagery is imagining yourself moving a body part. In the third chapter by Tim Beames, it is defined as a “process in which you are aware of yourself thinking about what you are doing” [-p. 79]. Through careful data collection, the researchers found out that this could still activate pain neurotags in some people (ouch, not good.) This means, for some people, even just imagining a movement can make their pain feel worse.

So the researchers proposed, and found, a way to get around that: “IMPLICIT” graded motor imagery is a delightfully sneaky process whereby movement-producing parts of the brain can be helped to rehabilitate, their neurons can be excited, but without activating any “pain” neurotags in the process!

The first stage is to help the brain relearn how to make left and right judgements about body physicality, both position of part itself, and various positions of various parts in space. Implicit motor imagery, or right/left judgment, activates pre-motor areas of the brain, which can then excite motor cells, but doesn’t directly activate them. The hypothesis is, that exposure to and engagement with implicit motor imagery can thereby sneak some learning in under the sensory-motor radar, so to speak, help the brain build the synaptic strength needed to undermine, inhibit and dampen the pain neurotag, because it can secondarily excite the motor area without activating either it or its connected pain neurotag! The brain will gradually and naturally tilt toward greater efficiency of inhibition, especially if it thinks changing is its own idea, that the change is coming from within instead of from without.

All of this sheds fascinating light on the “locus of control” aspect of brain function. It is a clever set-up indeed that can move locus of control around, and back and forth, right inside a brain!

Moseley has taken Melzack’s neuromatrix model of body-self a step further in his work, introducing the idea of a cortical body matrix, which integrates not just maps of the body, but also its surveillance, proprioception, regulation and protection, and not only the body - but also its surrounding space as well! The ‘cortical body matrix’ comprises a ‘network of networks’ - it includes “the suite of body systems that can be disrupted in a range of neurological and psychiatric conditions, including chronic pathological pain” [- p. 35].  He says that bias away from the “painful” side of the body includes a bias away from the space occupied by that part, as well; i.e., the brain prioritizes ‘away’ from the “painful” space. Delayed response time judging one side compared to the other led to this idea. Why the brain does this is as yet unknown; Moseley suspects the brain’s body-space maps may be disrupted somehow, although he isn’t fully committed to that idea quite yet.

Patients who embark on a course of implicit motor imagery training are counselled to enjoy the journey, not rush toward the destination - they are asked to develop and engage patience, persistence, courage and commitment. Possible pitfalls and obstacles are mentioned in the book, plausible explanations put forward.

The main tools for implicit motor imagery training are sets of cards depicting body regions and parts in various positions. The term “vanilla image” appears without warning on p. 45, without definition. (One must wait until chapter 5, p. 134, to learn from Tom Giles that “vanilla” refers to a “basic” image, on plain coloured background, without context, but one in which the body part has been randomly rotated 90, 180, and 270 degrees.) The patient is started with “basic” (unrotated, plain background) images, then “vanilla” images, and eventually moves to images of body parts inside a given context, i.e., how they might appear in magazines etc. The task is to decide as fast as possible, based on a quick glance only, if one is looking at a right or left side, or hand, or foot, etc. Scores improve over time as the brain’s synapses find each other after repeated exposure, and start to hook up. 

Figure 3.1 Flowchart showing ideal sequential progression of the different elements of graded motor imagery (GMI). From p. 61, The Graded Motor Imagery Handbook 

The third chapter by Tim Beames is a “nuts&bolts” description of the implementation of the program, outlining several how-tos, and what-ifs. Explicit motor imagery is a way of practicing a motor skill or activity which engages the brain parts involved, including the motor cortex, but without actually physically performing the motor actions - exercising the “virtual” body but not the physical one. The inner regulation control systems don’t really know the difference though - heart rate may respond to the imagined movement by increasing, for example. Patients graduate to this, and to mirror therapy, which involves the actual motor cortex to produce real movement, once they have successfully navigated implicit motor imagery, and have improved their right-left judgement scores. Graded exposure and pacing tips are woven throughout. Case studies are described. The goal is not just pain relief - the goal is to help the patient’s brain regain flexibility and creativity!

Butler returns in Chapter 4 to discuss stories, images and metaphors that can help move the process along.

In Chapter 5, Tom Giles explains how to set up a “Recognize” program on the computer or as a mobile app., essential aid to clinicians who want to integrate this whole system into a busy practice, or to patients who need to access it any time of the day or night.

I think prior exposure to neuroanatomy would be helpful, so I am including in this review an image I like very much from Mayo Clinic Medical Neurosciences 5th edition, depicting how inputs funnel themselves within the brain, from afferent sensory systems to output systems, premotor, and motor cortex. 

Fig. 16B.11 Hierarchical processing of information in cerebral cortex. From p. 713, Mayo Clinic Medical Neurosciences, 5th Ed. (2008) Benarroch EE et al., Informa Healthcare 

I would have appreciated having “vanilla image” explained earlier in the The GMI Handbook, or appear in the index, but I can also understand how individuals in a group, working feverishly on a project, may understand perfectly well what each other means and completely overlook the fact that no one outside the group may know what they mean by a certain word. (That is really my only negative criticism, and it’s a pretty small one!)

Overall this book is a pleasure to look at, handle, read, and use. It represents expansion of the profession beyond its ordinary knowledge base, providing hope to all clinicians who may be dissatisfied with the tools we were taught based on information that is no longer relevant, and to patients who want their practitioners to learn something new that might help them recover their own neural and movement capacities, and hopefully help their brains unlearn pain!

Thursday, May 10, 2012

Changing PT

After 40 years in this profession, it is ever clearer to me that at the individual level one has to become the change one wants to see in the world. 

I like this article I saw posted to Facebook today, Good to Great by Jim Collins. It talks about companies, but I think certain aspects apply just as well to professions. 

My two favorite excerpts (bolds and strikeouts and adds mine).

1. First, development:  
"Picture an egg. Day after day, it sits there. No one pays attention to it. No one notices it. Certainly no one takes a picture of it or puts it on the cover of a celebrity-focused business magazine. Then one day, the shell cracks and out jumps a chicken. 
All of a sudden, the major magazines and newspapers jump on the story: “Stunning Turnaround at Egg!” and “The Chick Who Led the Breakthrough at Egg!” From the outside, the story always reads like an overnight sensation—as if the egg had suddenly and radically altered itself into a chicken. 
Now picture the egg from the chicken's point of view. 
While the outside world was ignoring this seemingly dormant egg, the chicken within was evolving, growing, developing—changing. From the chicken’s point of view, the moment of breakthrough, of cracking the egg, was simply one more step in a long chain of steps that had led to that moment. Granted, it was a big step—but it was hardly the radical transformation that it looked like from the outside. 
It’s a silly analogy, but then our conventional way of looking at change is no less silly. Everyone looks for the “miracle moment” when “change happens.” But ask the good-to-great executives change agents when change happened. They cannot pinpoint a single key event that exemplified their successful transition."

2. Second, flywheel effect: 
"..picture a huge, heavy flywheel. It’s a massive, metal disk mounted horizontally on an axle. It's about 100 feet in diameter, 10 feet thick, and it weighs about 25 tons. That flywheel is your company. Your job is to get that flywheel to move as fast as possible, because momentum—mass times velocity—is what will generate superior economic results over time. 
Right now, the flywheel is at a standstill. To get it moving, you make a tremendous effort. You push with all your might, and finally you get the flywheel to inch forward. After two or three days of sustained effort, you get the flywheel to complete one entire turn. You keep pushing, and the flywheel begins to move a bit faster. It takes a lot of work, but at last the flywheel makes a second rotation. You keep pushing steadily. It makes three turns, four turns, five, six. With each turn, it moves faster, and then—at some point, you can’'t say exactly when—you break through. The momentum of the heavy wheel kicks in your favor. It spins faster and faster, with its own weight propelling it. You aren't pushing any harder, but the flywheel is accelerating, its momentum building, its speed increasing. 
This is the Flywheel Effect. It's what it feels like when you’re inside a company profession that makes the transition from good to great. Take Kroger, for example. How do you get a company profession with more than 50,000 hundreds of thousands of people to embrace a new strategy that will eventually change every aspect of every grocery store patient encounter? You don’t. At least not with one big change program. 
Instead, you put your shoulder to the flywheel. That’s what Jim Herring, the leader who initiated the transformation of Kroger, told us. He stayed away from change programs and motivational stunts. He and his team began You begin turning the flywheel gradually, consistently—building tangible evidence that their plans made new frame around the profession makes sense and would can deliver results."